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Der:171305:44a Reliable Petroleum 2098458953 p.2 12/17/2013 9: 18AM FAX 9252303 Guadalupe Sanchez • a0000�02/00�16/ MONITORING SYSTEM CERTIFICATIOxRECEI V ED For Use By ALI Jurisdictions Within the State of Col(forrrla A u0wriry Cited-Chapter 6,7,Health and Safety Code;Chapter 16.Divvion 3, Title 13,Cal fronto Cnde ofiAigidd}tc$ts20 13 This farm must be used to document testing end servicing of monitoring equipment. A =anme gcijificalign at r monitoring svgtem coatrnl panel by the techrucian who performs the work. A cropy of this form must be provided in it AL, 'Me owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of tua daldi EALTH DEPARTMENT A- Central Information Facility Name: ARCO Bldg,No.: Site Address: 4856 S.State Route li City: Stockton,Ca. zip: 95216 Facility Contact Pcrson: Gill Contact Phone Na; (208) 4B7-7445 Make/Model of Monitoring System: Veeder Raot TLS-350Date of Testing/Servicing: 11/19/2013 B. Inventory ofEquipment Tested/Certified Check then m inane huaes nes indicate s ei0r a ul went in "Jawservieol: Tank[n: 87 Tank m: 89 0 in-Tank Chniginm Probe, Model: 947390.109 ®In•Tuk Gauging probe, Model: 847090-7179 ®Homier Sparc ar Yautt Sensor. Madel: 794390497 0MnnLv Space orVwi[Sensm. Model! 794390.407 ®Fitt ng up Sar rnch Scmor(s). Model: T943aDx23 ®Piping Sump/Trench Scnsor(s). Model: 794300.329 ®Ptlt Sump Sari Mndcl: 794300.344 ®rill Sump Scasa(s). Markt: 79439D-323 ❑Mechanical Line Lark Defector. Mudd: ®Mechanical Linc Leek Deketor. Model: 99LD-2000 Eleerton;c I.meilLeak Ddcclor, Model: Pi 244-06" ❑ Rlccvonic Lice Leak Ociecuv, Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Ovwfili I High•Levol 3ensm. Model: []Other(spccily uipntent typo and model in Swim 15 an Page 2). ❑Utaer( a' eyui meat sP d7 p type and rrgdal in Sedioa}i mr Page Z). Tan k m: 91 Tank ID; ®In-Tank Qaug nS Probe. Modal: 847390.199 ❑In-Tank banging Probe Model: •Annular Space Tr Vaal[Sensor. Model: 794390407• El Annuli Space m Vault Sensor. Model: Piping Skimp/Traub Searwr(s). Model: 704390-323 ❑Piping Sump/Trench Saari Model a Fill Sump Scasor(s), Model: 794300-323 ❑Fill Sump Scrum(s), Madel Mechanical Line I.cak Detector. Model: 9910-2000 ❑Mechminl Linc Leak DCU Clor. Mudd: ❑Electronic Line Leak Octescuu. Model ❑Demonic Linc Leak Detector. Modal: ❑Tank Overfill/Higls-Level Sensor. Model: ❑Talk Ovcrfi:l I High-Level Scajmv.. Model ❑Other(specify wiuipmenl type and rrci it Smion a on Page 2) ❑Other(specify equipment type and model in Section E on Pai 2). Dispeaser.ID: 18.2 Dispeaser ID: 3&4 0 Dispenser Cantaiirment Sensor(s). Mndd: 794380323 ®Dispenses Cbnk;nnrenl Sensw(sJ. Model; 794390x23 ®Shear VpWe(s). ' 0 Shear Valvas). ❑Dispenser Contaiols"t Floats)and Chain(s). ❑Dispenser Cuntsinmcn:Flows)omf C:k m(s). Dhpomer m: 5&6 Dispenser Ill: 7&B ®Dfspeni Contalnment Sento(s). Madel, 794380.323 N nispemter Containment Sennn(s). Model: 794380.323 ITShcar valve(s), N Shcar valve($). L DL vtn&wCuitainmcmFIL,gt(s)an4C.Win(s). _ ❑Wpen.w Containment pbnt(s)and Chums). Dispenser ID: 9&10;11&12 Dispenser W: 13&14;15&16; 17&18 ®Dispareer Cortainment Smeor(s), Mudd: 794380.323 to Dispenser Containntma Sensor(s). Model: 7D43a0-323 ®Show Va;ve(s), (�Stear ❑Dispenser Canmi4ment Flaet(r)end Chain(s). ❑Didier sm Coutainmenl Fbaf(s)and Ch,m(s). •lf thafacility casthins mart tanks ur dispensers,copy[Is(s form.`include for every tank end dispraser m[the fuilttly. C. CehliTieatiOn - I certify that the equipment identified to this document was inspocted/setviced in accordance with ON manufacturers' guidelines. Attached to this Cartineadon is information(e.g. manufacturoo' cheektiats) accessary to verify that this information. is correct and a floe Plan showlael the layout of monitoring al111160L For any equipment capable of geaermiing such reports,I have also attached 9 cupy of the report;fetleck art that apply): ZZ System set-up ®Alarm hlstory report Technician Name(print): Guadalupe Sanchez Signature.— oaf f/ Certification No.:• A30138 License.No.: 883705 Testing Company,Name: Reliable Petroleum Services,Inc. Phone No.:(209) 845.8586 Testing Company Address: 11930 Horseshoe Rd,Oakdale,Ca. 95361 Datc of TesGng/Servicing: ll/1912013 Page 1 of 4 Rev{2108)